High Satisfaction Rating by Users of Private-for-profit Healthcare Providers-evidence from a Cross-sectional Survey Among Inpatients of a Private Tertiary Level Hospital of North India.

BACKGROUND: Evaluation of outcomes can help improve the quality of provision of services within a healthcare setting. There is limited report on patient satisfaction in private-sector in India although they provide three-quarters of healthcare services. AIM: The study was designed to report the level of satisfaction among inpatients of a private tertiary care hospital in India. MATERIALS AND METHODS: A total of 102 participants were recruited and their socio-demographic, health-seeking behavior, and satisfaction rating on various aspects of healthcare were elicited. A five item Likert scale was used to obtain the satisfaction rating. Data analysis was done with the help of Stata version-9. Proportions for the discrete variables and means with Standard Deviation for the continuous variables were obtained. RESULTS: All the participants were urban and from upper-middle or upper socio-economic strata. The participants reported a high level of overall satisfaction (93%) as well as high satisfaction with physicians (95%), the doctor's interpersonal skills (99%), nursing-care (93%), general services (94%), and pharmacy (88.1%). CONCLUSION: There was a high level of satisfaction reported by the participants at this tertiary level hospital. This might reflect the actual good quality services being provided by the provider or the nonannoying response, which cannot be ruled out.

Reduced mortality, paraplegia, and stroke with stent graft repair of blunt aortic transections: a modern meta-analysis.

OBJECTIVE: Stent grafting has become the first-line approach to traumatic thoracic aortic transections (TTAT) in some trauma centers due to a perceived decrease in morbidity and mortality compared with standard open repair. We reviewed contemporary outcomes of patients undergoing endovascular repair of TTAT (endoTTAT) and those undergoing open repair (openTTAT) to determine if current reported results support first-line use of endoTTAT. METHOD: Retrospective, nonrandomized studies published in English (>5 cases/report) involving TTAT listed in PubMed between 2001 and 2006 were systematically reviewed. Periprocedural outcomes between endoTTAT and openTTAT were analyzed. Mean follow-up was 22.9 months for endoTTAT (reported for 22 of 28 studies) and 48.6 months for openTTAT (reported for 5 of 12 studies). For statistical analysis, t tests were used. RESULTS: We analyzed 33 articles reporting 699 procedures in which 370 patients treated with endoTTAT and 329 patients managed with openTTAT. No statistical differences were found between patient groups in mean age (41.3 vs 38.8 years, P < .10), injury severity score (39.8 vs 36.0, P < .10), or technical success rates of the procedure (96.5% vs 98.5%, P = .58). In contrast, mortality was significantly lower in the endoTTAT group (7.6% vs 15.2%, P = .0076) as were rates of paraplegia (0% vs 5.6%, P < .0001) and stroke (0.85% vs 5.3%, P = .0028). The most common procedure-related complications for each technique were iliac artery injury during endoTTAT and recurrent laryngeal nerve injury after openTTAT. CONCLUSIONS: To our knowledge, no large multicenter prospective randomized trial comparing endoTTAT and openTTAT has been published in the literature. This meta-analysis of pooled data serves as a surrogate, demonstrating a significant reduction in mortality, paraplegia, and stroke rates in patients who undergo endoTTAT; however, the long-term durability of endoTTAT remains in question.

Endovascular repair of thoracic aortic tears.

BACKGROUND: Standard treatment of traumatic thoracic aortic transection (TTAT) is open repair by left thoracotomy with or without the use of partial cardiopulmonary bypass. However, open repair is associated with high rates of morbidity and mortality, particularly in multiply injured trauma patients. We reviewed our experiences of endovascular repair of acute TTAT. METHODS: Between February 2001 and February 2006, 30 patients (male 24, female 6, mean age 43 years) who had sustained severe blunt trauma with multiple injuries (mean injury severity score = 42) underwent endovascular repair for TTAT. Devices used included commercially available proximal abdominal aortic extension cuffs and thoracic stent-grafts. Either low dose or no systemic heparin was used. Arterial access was obtained by femoral-iliac cutdown (n = 19) or completely percutaneous through the femoral artery (n = 11). Mean follow-up was 11.6 months (range, 1 to 48 months). RESULTS: Technically success was achieved in 100% of patients, as determined by angiographic and computed tomographic (CT) scan exclusion of TTAT. Mean operating time was 132 minutes. Mean blood loss was 300 cm3. Three patients had complications: 1 iliac artery rupture, 1 cerebellar stroke, and 1 partial stent collapse. There were 2 perioperative deaths. There were no instances of procedure-related paralysis. Clinical and CT follow-up did not reveal evidence of endoleak, stent migration, or late pseudoaneurysm formation. CONCLUSIONS: The adaptation of commercially available stent-graft devices to treat TTAT is technically feasible, and can be performed with low rates of morbidity and mortality. The long-term durability of endovascular repair of TTAT remains unknown, but early and midterm results appear promising.

The history and development of direct coronary surgery without cardiopulmonary bypass.

The history of direct myocardial revascularization without cardiopulmonary bypass dates to 1961 in the dawn of coronary artery surgery. With the introduction and development of techniques of extracorporeal circulation around the same time, beating heart surgery was largely abandoned. Over the subsequent decades, cardiopulmonary bypass and electromechanical cardioplegic arrest became popular as means of revascularization in a bloodless and motionless field. While coronary artery surgery on the arrested heart remained undisputed for decades, myocardial revascularization on the beating heart was pursued by a few pioneering surgeons around the world, based on the belief that coronary revascularization could be performed equally well without the detrimental effects of cardiopulmonary bypass and electromechanical arrest. Various concepts and techniques developed during the 1980s by these pioneers enabled minimally invasive coronary surgery to be performed in the early 1990s. This break from the mainstream allowed selective myocardial revascularization using a minimal incision and no cardiopulmonary bypass to develop and constructed a base for future extensive revascularizations off-pump. With the subsequent explosion of new techniques for coronary exposure and myocardial stabilization, complete revascularization without cardiopulmonary bypass became possible with consistent results. Emerging from the preview of only a few surgeons just a decade ago, off-pump surgery is currently one of the accepted modalities for complete myocardial revascularization worldwide. This paradigm shift in the approach to myocardial revascularization has led to exiting new future possibilities, such as beating heart totally endoscopic coronary artery surgery.

Initial experience with sutureless proximal anastomoses performed with a mechanical connector leading to clampless off-pump coronary artery bypass surgery.

BACKGROUND: We report our early experience with the Symmetry Aortic Connector (St. Jude Medical, St. Paul, MN) used for sutureless proximal aortosaphenous vein graft anastomoses without any cross clamp during coronary bypass procedures. METHODS: Between November 2001 and August 2002, 206 saphenous vein to aorta proximal anastomoses were created in 132 patients using the Symmetry device. All procedures were performed as part of off-pump coronary artery bypass surgery without any aortic clamping. Intraoperative variables and postoperative data were collected and analyzed retrospectively. RESULTS: All 206 anastomoses (100%) were successfully completed with the connector. Severe atherosclerotic disease of the aorta was documented in 16 patients (12%). Four anastomoses (2%) required additional suture placement. Predeployment problems occurred with 3 grafts (2.5%) during loading of the connector. Average number of distal bypasses was 3.2 per patient. One patient (0.7%) required reoperation for bleeding from a proximal anastomosis. Six patients (4.5%) had perioperative myocardial infarction documented by electrocardiographic changes. Thirty-day operative mortality was 3% (4 patients). Intraoperative transit time flow measurement was performed in all cases (100%). Postoperative angiography in 43 patients at a median 3 months postoperatively revealed occlusion of 9 of the 81 saphenous vein grafts (11%). CONCLUSIONS: The initial experience with a proximal saphenous vein graft to aorta anastomosis using the Symmetry connector demonstrates safety and ease of use. There is however some concern with early graft closure. A prospective randomized study is needed to clarify these concerns.